Critical Care for Burn Injuries

N Dirty Nursing: Burns

The 60-Second Summary
5 Types of burns: Chemical, thermal, electrical, ionizing radiation, inhalation injury
Classification Systems: Rule of 9's (used in transport), Lund-Browder (more detailed, used in hospital
Hypovolemia: Vasodilation and inflammation causes increased vasculature permeability and fluid leaks out of neighboring cells
Airway obstruction: Potential for any burn that affects the chest up. Inflammation results from tissue damage, which can to lead to edema and
obstruct the airway. Greatest risk for death within the first 24 hours
Circulatory impairment: Eschar/necrotic tissue formation creates increased pressure and obstructs the vasculature. Most common with inhalation
injuries and circumferential burns. Evidenced by pulselessness

Understanding Burns
Initial Considerations for Burn Injury
Consider the source of the burn, the injuring agent, severity, depth, exposure, and baseline vitals/status. The Rule of 9s is usually used pre-hospital
(in transport by paramedics/EMTs) while Lund-Browder is used in hospital. In the Lund-Browder, the areas are divided more precisely than the Rule
of 9s. For instance, the Rule of 9s divides the arm as 9% (or 4.5% for posterior and anterior side), whereas the Lund Browder divides the arm into
the right upper arm, left upper arm, left lower arm, and hand.

The healthcare team members must take special considerations in cases of potential contamination to protect themselves first. After all, no patients
can be saved if everyone dies!

Special Airway Needs for Burn Injury

Any burn that affects the chest up is considered an airway problem. Damage causes inflammation, which can to lead to edema and obstruct the
airway. This is the highest risk of death within the first 24 hours. Proactive pain management is crucial, especially when mechanical scrubbing is
used. ABA consensus formula: 2-4 mL or crystalloid solution x body weight in Kg x TBSA to provide the total 24 hour fluid to be administered. This
amount is dived in half. The first amount is administered over the first 8 hours and the second half over the next 18 hours.

Why the Patient is at Risk for Hypovolemia

Vessels dilate and become more permeable to the membrane. Inflammatory mediators such as cytokines rush to the area of injury, causing
vasodilation and increasing the permeability. This causes fluid to leak out of the cells. Fluid administration is central to burn management as
it promotes tissue perfusion and reduces the risk of complications associated with dehydration.

Why the Patient is at Risk for Circulatory Impairment

In addition to fluid loss, circulatory impairment can result from necrotic tissue formation. Eschar complications are most serious in the lungs
(inhalation injuries) and in circumferential (all around burn) burns. In the circumferential burn causes bands of eschar, which creates pressure and
obstructs the vasculature, (evidenced by pulselessness).

Road Rash
Road rash can develop into burns. Entrapped debri embedded into the tissue can cause burns long after initial contact. Theyre treated the same
way as other burns, via hydrotherapy

Types of Burn Injuries

5 Major Types of Burns
Chemical, Thermal, Electrical, Ionizing radiation, Inhalation injury

Chemical Burns
Chemical burns are caused by exposure to acidic or alkaline compound or another noxious chemical. Its usually related to home or work exposure.
They are treated with hydrotherapy as soon as possible (rather than a neutralizer, as was the standard before). If exposure to the eyes occur, they
are continuously flushed until a specialist comes.

Thermal Burns
Thermal burns are caused by exposure to steam, smoke, flames, or a hot object
Common sources of thermal burns occur from scales secondary to exposure with hot food or beverages, or hot tap water from bathtubs or
showers
The severity of a thermal burn depends upon the temperature of the injuring agent, duration of contact, and to some extent, the actions taken
immediately afterwards (such as if someone follows the old wives tale of placing butter on the wound, which actually serves to trap in heat)
Moat beverages such as coffee, are served at a temperature of 160 to 180 degrees Fahrenheit (71-82 degrees Celsius), which can cause a
serious burn almost instantaneously upon contact
It can also increase the patients risk for dehydration, especially if they reside in a hot climate like Phoenix, Arizona in July
Electrical Burns
Electrical burns are caused by exposure to voltage. One of the major risks is cardiac issues. Voltage can travel to other deep areas. Low voltage is
defined as 1,000 volts (V) or less and travels through the path of least resistance. Even a small injury to the hand may require an amputation if
severe enough.

Common Sources of Burns

Thermal: hot beverages and foods, bathtubs, and other facets
Chemical: formic acid (cement, phenol, anhydrous ammonia), nitrates, hydrocarbons, tar, white phosphorus
Electric: electrical cord, utility box, occupational (especially construction workers), lighting

Inhalation Injury
The Effects of an Inhalation Injury
Inhalation injuries are less obvious that external burns but can potentially cause damage that is even more of an immediate threat to survival. They
may occur alone or in conjunction to external burns. Noxious gases produced by hot soot particles result as a byproduct of combustion. Inhalation of
these particles can inflict damage to the tracheobronchial tree, resulting in the loss of ciliary action, airway edema, and diminished production of
surfactant production. Eschar, which is necrotic tissue that is thick and leathery, can serve as a mechanical restrictive force in the airways.
Secondary consequences can result from pulmonary edema, chemical pneumonitis, and extensive mucosal sloughing

Common Sources of Inhalation Injury

Aldehydes, Ammonia, Hydrogen chloride, Hydrogen cyanide, Phosgene, Sulfur oxides

Complications
Promoting Survival in the Burned Patient
In addition to airway and breathing impediments, circulation impairment is a common complication associated with burn injury. Dramatic losses of
can easily induce hypovolemia, resulting in hypovolemic shock. Extensive cellular damage is often associated with hyperkalemia, as ruptured cells
release potassium into the vascular spaces. Thermodynamic regulation impairment is another major issue. Major dysfunction of metabolic processes
impair the bodys ability to retain heat. Additionally, the evaporative forces that affect exposed blood and fluid can rapidly lead to hypothermia.

The Only Warm Part of the Hospital???

Most students notice that the trauma rooms are much warmer than any other area. This is not a coincidence. Trauma rooms are purposely
maintained at a higher temperatures due to the patients risk of hypothermia.

Immediate Complications Associated with Burns

Circulation: hypovolemic shock
Circulation: hyperkalemia (can affect the heart)
Exposure: hypothermia is common complication that poses immediate risks to survival (from coagulopathies and cardiac arrhythmias)

Delayed and Secondary Complications

Metabolic acidosis may not present until later on. Dramatic alterations in fluid, electrolyte, and oxygenation status predispose the patient to
metabolic acidosis
Infection is a common secondary complication of burn injuries. Once the patient is stable, this is one of the most common events that can
threaten survival in the patient with a burn injury

Classifying Burns
Burn Severity
The severity of the burn is classified by the depth, anatomical location, and size. Burn depth of the burn is categorized as first, second, third, or forth
degree, depending upon the affected tissue. Certain burns are automatically promoted in severity if they affect sensitive anatomical locations, such
as the hands, face, or genitalia. The size of the burn is initially estimated by the percent of the body affected by the burn, determined by the Rule of
Nines or the Lund and Brower method
Burn evaluation is crucial for several reasons. Initially, it guides fluid administration for resuscitative purposes. Furthermore, it determines if the
patient requires specialized treatment by a burn center. Burn therapy is a highly advanced specialty. In order to increase survival and minimize
the effects of long-term consequences, patients with serious burns are transferred to the local burn center for specialized treatment

Burn Zones
Necrotic zone
Zone of stasis: triggers the release of inflammatory mediators such as histamine, prostaglandins, thromboxane, nitric oxide, which serve to
increase capillary permeability and result in localized burn wound edema. This is followed by production of highly reactive oxygen species (ROS),
causing additional propagation of the immune response
Immune reactions disrupt sodium-ATPase activity, which may contribute to burn shock, a combination of hypovolemic, cardiogenic, and
distributive shock (usually just known as hypovolemic shock)
Burn Size
The Rule of Nines divides the body into sections, with each area representing 9% (or multiple of 9%) of the total body surface area (TBSA). The
final 1% is represented by the perineum and genitalia. Scattered burns are estimated by the size of the patients palm, which is generally
proportionate to 9% of the total body surface area (TBSA). Calculating the TBSA is essential for fluid volume delivery and determining if the patient
needs to be treated in a burn center.
The Rules of Nines
Each arm: 9%
Anterior torso: 18% (add 5% for a pregnant woman in the third trimester)
Posterior torso: 18%
Each leg: 18%
Genitals: 1%

The Lund-Browder Chart

The Lund-Browder chart is a more complex and comprehensive method to measure the burn severity. Its usually utilized following the primary
survey, as its more time consuming. For children less than 12 years of age, the modified Lund-Browder chart is used, as its especially calculated
for pediatric body ratios, as the body surface area to mass ratio in children is higher than adults.

Degree of Severity
First-degree burns: only involve the epidermis
Second-degree burns: classified as superficial or deep and involve all of the epidermis and some to all of the dermis
Third-degree burns: also known as full thickness, affect all of the epidermis and dermis
Forth-degree burns: affect all of the skin layers and varying degrees of adipose tissue, bone, tendon, and muscles.

First-Degree Burns
Presentation of the First-Degree Burn
Red, tender, dry, branching, and painful
The heal within a week with no scarring
Damaged tissue sloughs off within a few days

Second-Degree Burns
Presentation of the Superficial Second-Degree Burn
Red, moist, painful, with a blister
Heal 10-14 days with no to minimal scarring

Presentation of the Deep Second-Degree Burn

Less red and not as painful
Heals within 2-4 weeks, often with significant scarring

Third-Degree Burns
Presentation of the Third-Degree Burn
Dry, leather-like texture with variable color; pain may be absent as the nerve endings are gone (pain will still be present in the area around the
burn)
Interventions required for healing to occur. A complex reconstructive process may be needed and recovery may take several months to years

Forth-Degree Burns
Presentation of the Forth-Degree Burn
Variable in presentation, as it affects the entire span of the epidermal, dermal, and adipose layers. Muscle, tendon, and bone may be missing
A high level of interventions are required for healing to occur, which often takes months to years. Amputation or a complex reconstructive process
may be required

Parkland Formula: 4 mL x Body Weight in Kg x TBSA % = Fluid Amount in mL

Burn Centers
What are Burn Centers?
Burn centers are specialized facilities that maintain a team of healthcare professionals that highly trained and qualified to manage the care of
patients with serious burns.
Referral Criteria for a Burn Center
All third-degree and forth-degree burns
Burns to the hands, face, genitals, or joints
Partial thickness burns that affect more than 10% TBSA
Electrical burns, chemical burns, or inhalation injury
Pediatric patients with a serious burn injury
Burn injuries that occur with concomitant trauma
Any burn injury that requires a special form of treatment that extends beyond the expertise of the facility

Trauma Management
ABCDE: Primary Survey and Actions for the Patient with a Burn
A: Airway. Use a chin lift or jaw thrust to position the patients head while assisting the trauma surgeon in placement of an oropharyngeal or
nasopharyngeal tube to maintain airway patency. Assess need for endotracheal intubation. Maintain in-line cervical immobilization for patients
at-risk (until cleared for C-Spine) during placement to the best of ability (airway management is the priority). Simultaneously perform an initial
estimate the burn area. Succinylcholine may be used only within the first 8 hours for incubation, and with extreme caution if a crush injury is
suspected
B: Breathing. Auscultate the lungs and verify breath sounds (both for the purpose of listening to the lungs and to perform the initial
confirmation of the airway tube). Assess respiratory rate, depth, and quality. Do this while administering humidified 100% oxygen. Monitor the
chest wall excursion for the presence of deep torso burns
C: Circulation. Monitor pulse rate and strength, blood pressure, and assess the skin color. Establish two intravenous access sites with a
large bore catheter wherever possible (through burned skin, if necessary). Initiate infusion of warm lactated ringers. Assess circulatory status of
circumferentially burned extremities. Apply electrodes for an EKG
D: Disability. Assess for neurological deficit by the patients monitoring level of consciousness. This is performed through conversation during
resuscitative efforts, assuming the patient is conscious. Most patients with burn injuries are typically alert and oriented. If not conscious,
consider the potential for associated injuries, including: carbon monoxide (CO2) poisoning, inhalation injury, substance abuse, hypoxia, or the
possibility of a pre-existing medical conditions
E: Exposure/Environment. Remove all clothing and jewelry, especially rings. Remove wet clothing, linens, and wet dressings. Maintain
the patients body temperature. Keep the room warm, eliminate drafts from the treatment area, and continue to administer warmed fluids
intravenously. Keep the patient covered with dry sheets, warm blankets (Mylar blankets), and wrap the head to maintain the patients body
temperature. Apply covered heat packs as appropriate. Use a moisture retainer on the endotracheal tube. Cover the burn with a clean, dry sheet
or blanket when its not being assessed

Secondary Survey and Actions for the Patient with a Burn

Data Collection. Collect information from the patient (if possible) and from other sources, such as witnesses and/or family members. The first
questions involve the situation surrounding the event, the possibility of concomitant trauma (especially head, thoracic, and abdominal injuries, as
these may not be readily observable), prescription medication use, and preexisting medical conditions. Use collected data to consider potential
sources of injury, including flame, flash, scalds, chemical, electrical, radiation, explosion, and contact, in order to provide information on the most
appropriate collaborative interventions. Determine if alcohol or drug use was involved in the injury (not to be judgmental, but to guide treatment).
When inquiring about preexisting medical conditions, take special notes of cardiac disorders, diabetes, and pregnancy
Chest X-Ray and CT Scan. A chest x-ray should be obtained (this is very important if theres a suspicion of inhalation injury). Concomitant
injuries also indicate the need for X-ray/CT scans.
12-Lead Electrocardiogram. An ECG specially if an electrical injury is suspected or for patients with a cardiac history
Blood Work. Draw blood for the CBC, arterial blood gases, and other tests (this is typically performed when IV access is being initiated;
however, its not as important of a priority as fluid administration)
Pregnancy Test. A pregnancy test must be performed for all females of childbearing age
High-Risk Patients. Special considerations are given for pediatric, geriatric, and diabetic patient populations
Toxicology. A urine drug screen and a serum alcohol level is performed. Alcohol levels can influence coagulation significantly. Additionally, a
patient who is intoxicated with alcohol is more likely to be dehydrated, as antidiuretic hormone (ADH) secretion is suppressed. In other words, the
patient was peeing all night long prior to getting burned. This may indicate the need for more aggressive fluid replacement

Although Prioritized
Although these actions are prioritized, many of them occur spontaneously. The Level I trauma team acts as a highly organized and efficient unit,
which can be thought of as a well-oiled machine. For instance, although drawing blood for the CBC is not nearly as crucial as airway access, one
nurse may be obtaining the blood sample as the other one assists the trauma surgeon with airway placement.
Diagnostics
Chest X-ray: a chest x-ray is obtained in the trauma room but may also be ordered later (this is very important if theres a suspicion of inhalation
injury).
Doppler ultrasound: used to assess pulses. May be used during the primary survey, especially in cases of circumferential burns
CT scan: concomitant injuries also indicate the need for a CT scan
ECG are usually routine, but are an especially important to initiate early on for cases of potential electrical injury and for patients with a cardiac
history. Any patient with traumatic injury is at risk for atrial fibrillation. A-fib often sets the stage for the sequel of events that progress to premature
ventricular contractions, ventricular tachycardia, and ventricular fibrillation, which is a perimeter of cardiopulmonary arrest

Lab Values
Complete blood count (CBC), especially hemoglobin, hematocrit, and platelets
Basic metabolic panel (BMP), especially blood CO2, blood glucose and electrolytes, with a special emphasis on potassium, sodium, and
chloride, and renal function tests, including blood urea nitrogen (BUN), creatinine, and BUN/creatinine ratio
Urinalysis
Lactate
Arterial blood gases (ABGs), blood pH, and carboxyhemoglobin
Draw blood for the CBC (hemoglobin and hematocrit being the most important components)

Fluid Resuscitation
Fluid Replacement Principles
Fluid replacement is one of the primary interventions provided for the patient with a burn injury. Lactated ringers, which are isotonic fluids that
contain electrolytes, are administered for the first 24 hours. The amount of fluid is calculated through a formula such as the Parkland. Half of the
volume is administered during the first 8 hours and the second half during the next 16 hours. Following the initial 24 hours, colloid fluids, which are
hypertonic and contain large molecules that dont diffuse through the semipermeable membrane of the cell, are administered, usually for the entire
duration of day two.
The patient must be weighed daily. A weight gain up to 15% of the patients pre-treatment body weight can be expected as a result of the massive
fluid replacement. Once a significant diuresis occurs, the patient is determined to be out of the initial resuscitative phase. Fluid volume replacement
is then reduced by half. A urine output of 30-70 milliliters per hour is maintained. Special fluid replacement considerations are given for the patients
unique situation. For instance, electrical burns may require additional fluid. Patients with altered renal function that preexisted the injury may warrant
alterations to the standard fluid replacement algorithm.

Fluid Balance
Fluid administration is a central component of burn management. It maintains tissue perfusion by correcting blood loss. This reduces the risk for
hypovolemic shock. Fluids are administered at room temperature in order to reduce risks associated with hypothermia. However, fluid administration
is a delicate balancing act that requires careful titration. The end point of fluid resuscitation isnt clearly established and consequently requires the
need to examine the entire clinical picture. Complications associated with fluid overload can occur if too much fluid resuscitation is administered.
Indications That We Are We Giving Enough Fluid
Urine output of 30 mL to 70 mL per hour
Osmolality within normal range
Renal function values: BUN, creatinine, and BUN:Cr ratio within range
Lactate level stable (Fahlstrom, Boyle, & Flynn Makic, 2013)
hematocrit, serum electrolytes, osmolality, calcium, glucose, and albumin
Intake and output

Indications That We Are Giving Too Much Fluid

Excessive swelling and weight gain more than 15% of pre-injury weight
Dilutional hemoglobin and hematocrit
Pulmonary edema: evidenced by lung crackles
Abdominal compartment syndrome
Acute lung injury
Acute respiratory distress syndrome
Increased lactate levels (Fahlstrom, Boyle, & Flynn Makic, 2013)
Dialysis may be indicated for fluid overload associated with acute kidney injury
Lactate
Lactate values are obtained along with arterial blood gases in order to assess for elevated levels. Theyre carefully monitored to guide fluid
resuscitation. Rapid decreases in lactate suggested significant improvement in both tissue perfusion and oxygenation. Sustained elevation or
increase suggests that fluid resuscitation is inadequate or not improving perfusion for another reason. Organ dysfunction is present in this case.
Lactate monitoring is especially valuable as occult tissue hypoperfusion may still be present despite normotension and adequate urine output.
Lactate serves as a clinical marker to determine systemic hypoperfusion or sepsis severity. In burn cases, elevated lactate levels, or
hyperlactatemia, is indicative of tissue hypoxia associated with the burn injury (burn-related cases of hyperlactatemia are caused by tissue
hypoxia). Severe hyperlactatemia is considered lactic acidosis when it reaches levels of 5 mmol/L or greater. Lactic acidosis often occurs in
conjunction to metabolic acidosis.
Tissue hypoperfusion associated with burns (and other severe traumatic injuries, or septic or hemorrhagic shock states) trigger anaerobic
metabolism. This metabolic state increase the production of various acids, including lactic acid. Hyperlactatemia can suggest that the patient is in
shock or at risk of going into to it soon, and indicates intravascular volume deficit or cardiovascular collapse.

Lactate Levels
Normal lactate levels are under 2 mmol/L and typically implies that the patient has adequate tissue perfusion
Lactate levels between 2 to 4 mmol/L are considered to be a mild-to-moderate elevation
Lactate levels greater than 4 mmol/L are predictive for poor patient outcomes and higher mortality rates
Lactate levels of 5 mmol/L or greater is defined as lactic acidosis and is often accompanied by metabolic acidosis

Reparative Phase
Caring for Patients in Recovery
Once the diuresis occurs and the patient is not displaying complications associated with pulmonary issues related to inhalation injury, the reparative
phase begins.
Considerations for the Reparative Phase
Pain control
Nutritional support: promotion of gastric motility and prevention of hypercatabolism to lower risk of infection
Musculoskeletal support: contracture prevention and functional promotion
Wound care and debridement

Pain Control
Pain control is fundamental part of management. First degree and second-degree burns that are superficial are often the most painful as deeper
injuries damage the nerve endings involved in nociception (pain stimulus). However, the area surrounding more serious burns are also affected by
pain.

Nutritional Support
Enteral therapy is initiated within 24 hours. This is important for two main reasons: promoting gastric motility and preventing excessive metabolism of
protein. Gastric motility must be maintained in order to prevent sepsis from occurring, which can result from translocation of gastrointestinal bacteria.
This is one of the links between the high infection risk in burn cases.
Serum protein levels are monitored throughout therapy. Protein delivery is a delicate balancing act. Insufficient amounts promote catabolism. On the
other hand, excessive amounts can induce hypercatabolism. Excessive protein metabolism, known as hypercatabolism, produces high levels of the
waste product urea, which causes azotemia. This is one of the links between metabolic acidosis in burn cases.

Musculoskeletal Support
Physical and occupational therapy usually begins 24 hours after arrival. Various factors predispose the patient to muscular hypertrophy, which can
lead to contracture. Range of motion exercises are performed, usually with each dressing change and during hydrotherapy.

Wound Care
Hydrotherapy has become the most highly utilized treatment approach to manage burns. 20-30 minutes prior to wound care, an opioid analgesic is
administered. Additional doses are administered as needed throughout the treatment. Topical antimicrobial agents are applied to the wound area.
Various products are available, such as silver nitrate, neomycin, and bacitracin. Selection is determined by the physician, and is based off factors
such as the location, injuring agent, and severity of the burn. The amount of cream or ointment that is applied depends upon the needs of the wound
and the manufacturers directions. Escharotomy, and fasciotomy may be included as part of the treatment so wound care considerations must be
adjusted for specific needs.

Hypothermic Regulation
Thermodynamic regulation is crucial to the patients survival. Ability to maintain normothermia is altered by the impaired physiological function,
disturbing the bodys heat production. Furthermore, the burn can increase heat loss. Hypothermia predisposes the patient to risks such as
coagulopathies.
Wound Debridement
Wound debridement can be performed through surgical, chemical, or mechanical methods. The American Burn Association recommends that blisters
over centimeters in diameter be debrided. Debride blisters more than 2 cm in diameter. The burn wound is initially cleansed with chlorhexidine
gluconate solution. Once rinsed, an antibacterial cream is applied and then wrapped with a gauze dressing.

Nursing Care Planning

Nursing Assessment
Estimate the burn size (TBSA) and severity (degree)
Determine if concomitant trauma is present
Inquire with the patient (if possible), first-responders, family members, or any witnesses about the source of injury, time, and circumstances
surrounding the event

Potential Nursing Diagnoses

Ineffective airway clearance related to tracheal edema secondary to inhalation injury
Impaired gas exchange related to interstitial pulmonary edema
Fluid volume deficit related to diuresis, fluid shifts, and evaporative water loss
At risk for infection related to loss of integument, impaired tissue perfusion, and invasive therapy
Ineffective tissue perfusion related to impaired extremity vascular perfusion with circumferential burns
Acute pain related to thermal, chemical, electrical, or radiation burn injury
Hypothermia related to decreased heat production and increased heat loss secondary to burn (specify type) injury
Altered nutrition, less than body requirements, related to increased metabolic demands

Nursing Interventions for Fluid Volume

Calculate fluid volume to be administered. Use the Rule of 9s to determine the TBSA or the Lunds-Browder chart. Take the TBSA and plug into
the Parkland formula (4 mL x body weight in kg x percentage of TBSA burned = the amount of fluid in mL) or the modified Brooke formula (2 mL x
body weight in kg x percentage of TBSA burned = the amount of fluid in mL)
Administer lactate ringers for the first 24 hours (volume is determined by a formula such as the Parkland). Half of the fluid is administered during
the first 8 hours and the remainder over the next 16. After the first 14 hours, colloid solutions are administered in combination with fluids without
electrolytes for adults
Monitor the patients weight. A weight gain of 15% may be expected due to the massive fluid replacement. Monitor for potential complications
associated with fluid overload by obtaining labs for CBC (hemoglobin, hematocrit), CMP (BUN, creatinine), and lactate

Nursing Interventions for Hypothermia

Maintain a warm environment in the treatment and recovery areas by eliminating drafts
Administer intravenous fluids that are warmed to room temperature
Use Mylar blankets (look like tin foil) and warmed blankets
Assess the patients core temperature frequently
Monitor coagulation labs

Nursing Interventions for Infection Risk

Provide for wound care
Facilitate schedule for wound debridement
Administer prophylactic antibiotics as ordered
Administer a tetanus shot upon arrival to trauma setting, per facility protocol
Obtain orders for a CBC with differentials to monitor the WBCs. Take note of a shift to the left